After the shift change, which patient in the emergency department should the nurse prioritize for assessment?
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight.
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools.
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse.
A 50-year-old patient reporting sudden, severe upper back pain.
The Correct Answer is B
Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.
Correct Answer is D
Explanation
Choice A rationale
Atrial Flutter is a type of arrhythmia where the atria beat regularly, but much faster than usual. The treatment for Atrial Flutter is typically medication, not cardioversion.
Choice B rationale
Ventricular Tachycardia is a fast, abnormal heart rate. It starts in your heart’s lower chambers, or ventricles. Ventricular Tachycardia is a serious condition and can be life-threatening. While cardioversion can be used in some cases, it is not the primary treatment.
Choice C rationale
Atrial Fibrillation is when the upper chambers of the heart (atria) beat irregularly. This causes the atria to twitch, leading to an abnormal heart rhythm. The treatment for Atrial Fibrillation is typically medication, not cardioversion.
Choice D rationale
Ventricular Fibrillation is a life-threatening heart rhythm that results in a rapid, erratic heartbeat. During Ventricular Fibrillation, the heart quivers and can’t pump any blood, causing cardiac arrest. The treatment for Ventricular Fibrillation is Defibrillation.
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